A significant subgroup of suicidal adolescents continues to demonstrate suicidal ideation and behavior after discharge from emergent psychiatric care. These adolescents are typically high utilizers of expensive follow-up psychiatric care after discharge from inpatient psychiatric settings. This group of adolescents is the focus of this application. We are aware of only 6 RCTs with suicidal adolescents, two using family therapy, two using group therapy, one using Multisystemic Therapy, and a study by our group using individual adolescent Cognitive Behavioral Therapy (Donaldson et al, 2005). Only one of these six studies reported a reduction in suicide attempts at follow-up. We recently completed a study (Esposito-Smythers et al, in press) using an integrated adolescent and parent CBT protocol for adolescents with depression, suicidality, and a substance use disorder. At follow-up, our protocol resulted in fewer suicide attempts, re-hospitalizations, ED (Emergency Department) evaluations, and residential placements relative to standard care. These data are remarkable for the cost savings in the experimental group if ED evaluations, repeat inpatient psychiatric hospitalizations and residential placements are considered. In addition, our 5% rate of repeat attempts in the experimental condition over 18 months is very low compared to naturalistic studies and other treatment studies. Our protocol required two therapists per family - one for the adolescent and one for the parent(s) due to the acuity and severity of these adolescents. Not all suicidal adolescents will need an intensive treatment protocol such as ours but many being discharged from inpatient psychiatric care will need such services. In this application, depressed, suicidal adolescents seeking emergency care in an ED or who are psychiatrically hospitalized are eligible for our study if they have at least one additional risk factor: a prior suicide attempt, nonsuicidal self-injury (NSSI), and/or a substance use disorder, because these factors are related to increased risk for continued suicidal behavior and expensive contacts with the health care system after discharge. These risk factors were also chosen for scientific reasons because they share common underlying mechanisms - affect regulation and impulse control - that can be addressed in an intensive treatment protocol. The purpose of this application is to conduct a two group randomized controlled trial to test the primary aim that an intensive protocol designed to treat depressed, suicidal adolescents with an additional complicating risk factor will produce better treatment outcomes compared to standard care at the end of the active treatment (6 months), end of maintenance treatment (12 months) and at the final follow-up point (18 months).. This application's clinical significance lies in its addresing a critical barrier to the field: how to best treat the most high risk, depressed and suicidal adolescents. PUBLIC HEALTH RELEVANCE: The purpose of this application is to conduct a two group randomized controlled trial to test the primary aim that an intensive outpatient protocol designed to treat depressed, suicidal adolescents with an additional complicating risk factor, substance use and/or nonsuicidal self-injury, will produce better treatment outcomes than standard care. This application's clinical significance lies in its addressing a critical barrier to the field: ho to best treat the most high-risk, depressed and suicidal adolescents. The public health relevance of this application is evident as it addresses Healthy People 2020 Objective MHMD HP 2020- 2: Reduce suicide attempts by adolescents as well as NIMH Strategic Objective 3.1 to develop interventions.